SEQUENTIAL INTERCEPT MAPPING ASSESSING THE BEHAVIORAL HEALTH CRISIS - - PowerPoint PPT Presentation

SEQUENTIAL INTERCEPT MAPPING

ASSESSING THE BEHAVIORAL HEALTH CRISIS SYSTEM IN YELLOWSTONE COUNTY DAY TWO

JULY 16, 2019

Updates from Kristen Lundgren

19 Executive Committee 38 Steering Committee 120 Members 58 Organizations

3

May 2018

Est.

Jun-Dec

Funding, Structure

Jan – April

Consultants Secured Assessment Begins

June 30

Assessment Completed

July 16- 17

Sequential Intercept Mapping 1

4

5

GOAL Aug 2019

Collective Impact

Sep

SIM 2

Oct-Nov

Planning

Dec

Plan/Toolkit Completed

Jan

Implement

PREVENTION: Communities That Care planning GRANT Notification: Prevention, HIDTA

ONCE INDIVIDUALS WITH BEHAVIORAL HEALTH CONCERNS ARE IN THE JUSTICE SYSTEM, THEY OFTEN RECIDIVATE

• Courts
• Jails/Prisons
• Probation/Parole

Recidivism Cycle

THE FUTURE: A JUSTICE SYSTEM THAT APPROPRIATELY DIVERTS/LINKS INDIVIDUALS WITH BEHAVIORAL HEALTH CONCERNS TO TREATMENT THAT ADDRESSES ROOT CAUSES

Treatment and recovery

Jails Prisons Probation and Parole

WHAT ARE OUR GOALS?

• Avoidable crises

Reduce

• Utilization of high cost/ineffective responses (ambulance, ER, inpatient services jail, prison)

Minimize

• Appropriate assessment and diversion as early as possible

Maximize

INTERCEPT -1: YOUTH PREVENTION

Task Forces/Coalitions

¡

Best Beginnings Council

¡

Youth Volunteer Corps

¡

Communities That Care Organizations providing prevention services…

¡

Schools

¡

Church Organizations

¡

CASA

¡

Big Bothers, Big Sisters

¡

State of Montana Block Grant Funding-Prevention Specialist-Mental Health Center

¡

Out of school time programs: Boys and Girls Club, Care Academy, Discover Zone, YMCA, Friendship House, Homework Zone

¡

Billings Clinic, St. Vincent’s Healthcare and RiverStone prevention programs

¡

Home visiting/Parent Support: Family Tree Center, Family Support Network, RiverStone

Schools

¡

9-12 Rimrock and Tumbleweed

¡

6-8 YBGR

¡

K-5 curriculum – health classes

¡

RiverStone Health Clinics-health education in schools

¡

School Based Health Clinic in Lockwood

¡

Billings Clinic and St. Vincent’s Healthcare-classes

¡

K-8 Comprehensive School and Community Treatment – AWARE, Youth Dynamics YBGR

¡

SROs in middle and high schools

¡

SOS and suicide protocols

¡

Early Headstart and Headstart

¡

Educational Talent Search

¡

Upward Bound

¡

Trauma-informed education, resiliency training, mentorships and creative

• utlets/extracurriculars

*Need to flesh out the type of prevention services provided, source of $

INTERCEPT -1: YOUTH TREATMENT PROVIDERS Outpatient

¡ YBGR* ¡ Youth Dynamics* ¡ AWARE ¡ New Day* ¡ Rimrock* ¡ Youth Services Center* ¡ Montana Community Services ¡ Urban Indian Clinic-starting ¡ YWCA ¡ RiverStone Health ¡ Billings Clinic and St. Vincent Healthcare ¡ Private providers

Inpatient

¡ Rimrock* ¡ Billings Clinic

Residential

¡ Youth Dynamics* ¡ Yellowstone Boys and Girls Ranch

(YBGR)*

¡ New Day*

*Indicates providers who receive referrals from justice system (list not comprehensive)

INTERCEPT -1: ADULT TREATMENT PROVIDERS

Outpatient

¡

Mental Health Center

¡

Rimrock*

¡

Billings Addiction Counseling

¡

YWCA

¡

New Day*

¡

Community Medical Services (for profit methadone/buprenorphine)

¡

Ideal options (buprenorphine)

¡

Urban Indian Clinic (starting)

¡

• St. Vincent Healthcare and Billings Clinic

¡

RiverStone

¡

DOC Facilities: Montana Women’s Prison, Alternatives, Inc. Inpatient

¡

Rimrock*

¡

Billings Clinic and St. Vincent Healthcare Department of Corrections

¡

Alternatives Inc* *Indicates providers who receive referrals from justice system (list not comprehensive)

INTERCEPT -1: RECOVERY SUPPORTS

Groups

¡ Al-Anon/NA ¡ The Phoenix ¡ ALATEEN ¡ Dual Recovery Anonymous ¡ Rocky Mountain Tribal Leaders Council (RMTLC) ¡ PAR Groups ¡ NAMI

Other recovery supports

¡ The Phoenix ¡ IPS Supported Employment for ages 16-26 ¡ HRDC Youth Employment Opportunity Act

Peer support specialists available through

¡ Rimrock ¡ Rocky Mountain Tribal Leaders Group ¡ New Day ¡ Urban Indian Health Center ¡ YBGR

INTERCEPT -1: SOBER LIVING/HOUSING

Emergency Shelter

¡

Tumbleweed (not necessarily sober housing per se, but shelter is drug and alcohol free)

¡

Montana Rescue Mission-dry emergency shelter-not sober housing Transitional Housing

¡

Community Leadership Development Inc - Koinonia Mgmt Co

¡

Veteran’s of America Independence Hall

¡

HRDC Harmony House

¡

Adullam House Sober Housing

¡

Ignatia House

¡

CLDI Hannah House

¡

Rimrock: True North

¡

Sober Beginnings (Kenzie House, Ruthie House, Oxford House)

¡

*(Mentioned but could not find online presence: Butterfly House, Codee’s House and STEPs Recovery Homes)

INTERCEPT -1: OTHER COMMUNITY

• BASED SUPPORTS

90+ programs, services… Provided by:

¡ non-profits ¡ local and state government ¡ private entities ¡ faith community

Geared toward:

¡ Children ¡ Families ¡ Adults

Address:

¡ Economic support ¡ Employment ¡ Health services ¡ Food security ¡ Housing and shelter ¡ Training and skill-building

Intercept 0 Community Crisis Services Intercept 1 Law Enforcement & Emergency Services Intercept 2 Initial Detention & Initial Court Hearings Intercept 3 Jails & Courts Intercept 4 Reentry Intercept 5 Community Corrections & Community Supports

.

COMMUNITY

Treatment Courts Family Court (only for CFS involved families), Felony, Misdemeanor, Veterans, DUI court. Pre-trial Diversion Court in development

Jail Reentry Little re-entry coordination. Two social worker supports OPD clients Arrest

Violations Overnight Shelter Montana Rescue Mission (129 beds-men, 1411 beds-women & children) Gateway Domestic Violence Shelter Independence Hall-Vets 911 Dispatch Run by the Fire Dept Walk in Behavioral Healthcare- Business Hours Riverstone Helathcare for the Homeless, YWCA, Rimrock (working

• n same day

admits) Crisis Community Center, Mental Health Center No mobile crisis response Program of Assertive Community Treatment Team providing intensive, wrap around support for clients with SDMI. Caseload

• f 80. Slots currently available.

Violations Ambulance-run by American Medical Response, with a few rural volunteer services Youth Services Center Half detention beds, half shelter beds Crisis Lines Community Crisis Center Mental Health Center-for existing clients Gateway and YWCA Crisis Line Veteran’s Administration United Way 211-not a crisis line but can direct to crisis resources Montana Mental Health Peer Warm Line (M- F 4-8 pm and Saturdays 2-6pm) Suicide Hotline/Text Line run by DPHHS Law Enforcement Transport 13th District Court- felony criminal, general, jurisdiction, many drug case-8 judges with high criminal and dependent neglect caseloads Justice and Municipal Courts 2 judges Tumbleweed Youth Crisis Line 24/7 line for youth

Hospitals St. Vincent Healthcare ED (LACs

in ED, limited inpatient behavioral health, medical detox if needed) Billings Clinic-Medical Detox Psychiatric Stabilization Unit (capacity for 20 adults and 10 youth-23 hr 59 minute stays) Inpatient Psychiatric Center-80 beds Referred to Child Protective Services or Youth Court Services Youth Probation and Parole 9 officers, funding for community services, majority

• f cases diverted

State Probation & Parole Conducts pre- sentence investigations for

• felonies. Includes

assessment of behavioral health

Majority of cases deferred to probation

Day Shelter

• St. Vincent DePaul

The Hub Billings Clinic Lobby YWCA Salvation Army Rainbow House

Crisis Stabilization and Detox

Crisis Community Center (18 beds)- Social detox (23 hours, 59 minutes) Rimrock-12 beds medical 3 day detox Law Enforcement Yellowstone County Sheriff’s Dept (58 officers); Billings PD (150 officers), Laurel PD (12 officers) CIT for LE –12 CIT instructors and officers also trained in de-escalation Other Law Enforcement partnerships: Search and Rescue, Highway Patrol, U.S. Marshals Standardized CIT form filled out and given to Emergency Department DOC Pre-trial Safety Assessment Offenders released to the community- can utilize SCRAM, 24/7 or GPS monitoring, no pretrial services or mandated treatment Veteran’s Administration Veterans identified by self report- VA notified. No standardized mental health or substance use assessment Yellowstone County Detention Center 286 beds for men, 148 beds for women. 3 contracted mental health providers. Telespsych available for medication

• management. Inmates can access AA, NA

and spiritual groups. Jail staff receive critical incident training. Screened, referred by Defense, and sentenced by Judge (for post-adjudication courts)

Rimrock Re-entry Beds 7 men, 6 women

Women’s Prison Substance use and mental health treatment, Psychiatry AA/NA/Al-Anon Alternatives Inc Treatment for felons in DOC-commit and pre-release facilities- Passages (women), Alpha House (men) School Resource Officer Intercepts youth in crisis at school Law Enforcement Transport Arraignment Within 72 hours. Function oriented medical history provided by the detention center. Evaluation Detention center asks question at booking and medical staff evaluate health post booking. Behavioral health screening only done if medical staff determine need & refer to mental health. Jail Assessments Fitness to proceed can be requested by OPD, prosecutor

Probation & Parole 25 officers (high caseloads approx.100-lots of substance abuse/co-occurring disorders) DOC policies increasing caseloads but not resources.1 LAC on staff. Make referrals to community providers. Officers are required to do 1 hour of mental health training per year. Some are CIT trained. Standardized assessments for all offenders-women’s measures mental health. Officers refer to many local providers and link to other supportive services. Probation works with local providers for sanctions before revoking clients.

Youth Court- Within District Court, 18 or younger, misdemeanors/felonies .

Youth: Arrest

• r transport

to shelter bed

Billings Clinic provides DOC training via Project ECHO Corrections Reentry More prisoners being released to

• community. Little re-entry

coordination with men’s prison. Better coordination with pre-release centers and women’s prison.. Released inmates connected to Medicaid. Probation and Parole has a re-entry

• fficer who coordinates.

Bond For inmates let out on bond, some are required to do drug/alcohol testing, 24/7,

• r other monitoring. Only those revoked

for felonies receive monitoring by probation officers.

COMMUNITY

Return to parent or guardian Youth Court Services Coordinates next steps for youth in shelter beds

BASED ON THIS INVENTORY

Where is the system strong? Where is the system weak? Where are the

• pportunities for

improvement?

What works? Intercept -1: Prevention

THE PREVENTION CHALLENGE

Tertiary-already affected Secondary-at risk Primary-universal

ADVERSE CHILDHOOD EXPERIENCES

Understanding Adverse Childhood Experiences

Characteristics

• f successful

prevention initiatives

Comprehensive- not just awareness raising Sufficient dosage Positive relationships + well trained staff (or peers) Appropriately timed and socioculturally relevant Evaluation

MULTI SECTORAL, COMMUNITY WIDE, ENVIRONMENTAL APPROACH

Community norms Childcare or school Family Child

TARGET RISK AND PROTECTIVE FACTORS

KEY ACTIVITIES TARGETING RISK AND PROTECTIVE FACTORS (FUNDED BY DRUG FREE COMMUNITIES FEDERAL GRANT)

Opportunities for participation in activities that reduce risk and increase protection

Provide

Access/reduce barriers to protective systems and prevention initiatives

Enhance

Consequences

Change

Skills (providing training and technical assistance in systems)

Enhance

Physical design

Change

Policies

Modify/change

EFFECTIVE PREVENTION ACTIVITIES

FOCUS ON EVIDENCE BASED INTERVENTIONS

Nurse Family Partnership The PAX Good Behavior Game The Incredible Years Family Spirit Zones of Regulation Family drug courts: Children Affected by Methamphetamine

AVOID WHAT DOESN’T WORK

Waiting until high school DARE-like programs Fear/Risk based messaging

What works? Intercept -1: Community Based Treatment

MAJOR SHIFTS IN SUD TREATMENT

Treatment limited to SUD providers Universal screening, integrated care Evidence based practice including medication assisted treatment Community based treatment, building a continuum of care Abstinence model Focus on inpatient beds

Treatment not covered by insurance, funded by federal block grants + state dollars

Coverage mandated, covered by Medicaid

320

Professional peer support and recovery Informal recovery support

INTERCEPT -1: TREATMENT AND RECOVERY

• Universal screening/referral for MH and SUD in all possible settings
• Integrated behavioral healthcare models
• Ongoing continuum of care and treatment available to consumers as we have for

chronic disease

• Focused efforts to assist high needs consumers known to the system
• Case management and connection to community-based services including those

addressing SDOH (i.e., housing)

• Peers as a potential workforce in rural areas
• Recovery and social supports (AA, NA, MA, Phoenix)
• Comprehensive evidence-based programs (i.e., MATRIX)

Universal Assessment Warm hand offs/referrals Treatment Planning Behavioral Therapy Monitoring Case Management Pharmocotherapy Recovery & Peer Support Continuing care Vocational services Medical care

Education and childcare services Legal services Housing/ transport

Financial services

FOR METHAMPHETAMINE: COMPREHENSIVE, LONG TERM BEHAVIORAL THERAPIES

Behavioral therapy Family education Individual counseling Encouragement for non-drug related activities Drug testing 12 step support

• Cognitive behavioral therapies
• Contingency management

intervention

MOTIVATIONAL INCENTIVES FOR ENHANCING DRUG ABUSE RECOVERY (MIEDAR),

Provides rewards (monetary and prizes) for submitting and testing negative through urine analysis and breath testing Participants earn up to $400 in prizes over 3 months

WORST CASE CRISIS SCENARIO IN MONTANA

Individual in crisis Law Enforcement Transfer to Inpatient Treatment Jail ER or Hospital with no behavioral health assessment

No follow up or linkage to community-based behavioral health care providers after the crisis is resolved No triage or assessment by qualified behavioral health professional

Gallery Walk of example behavioral health crisis systems

REGIONAL CRISIS SYSTEMS OVERVIEW

Best Practice Models for Rural BH Crisis Response

USE OF PARAPROFESSIONALS AND TECHNOLOGY

Alaska

BEHAVIORAL HEALTH AIDES STATEWIDE TELEHEALTH “HUB”

• consult and support to BH aides and other

paraprofessionals

• allows patients to be seen by professionals
• determination of when patients need transport
• case management, routine care and med management
• assess and resolve crises, and refer
• training is key

16 COUNTY REGIONAL CRISIS SYSTEM

SE NEBRASKA

MOBILE CRISIS RESPONSE COUNSELORS LAW ENFORCEMENT CIT TRAINING REGIONAL

• CRISIS STABILIZATION CENTER FOR INVOLUNTARY

PROTECTIVE CUSTODY PLACEMENTS

• SOBERING, DETOX AND TREATMENT CENTER
• counselors respond to LEAs in person or virtually with

secure iPad technology

• 24/7 emergency community support case managers
• connect with clients during crisis event and for up to 90

days

REGIONAL CRISIS CENTERS

IDAHO

23 hour, 59 minute stays 24/7 nursing staff assess before admission Daytime bachelor’s level SWs Psych techs 24/7 Clinical supervision provided weekly for MH and SUD

RURAL CRISIS STABILIZATION PROJECT

24/7 CRISIS ROOMS IN FIVE CRITICAL ACCESS HOSPITALS STAFFED BY TEAMS FROM EXISTING LOCAL ORGANIZATIONS

• ED staff – medical stabilization
• Clinicians from Behavioral Health – assessment and

evaluation, treatment, safety planning

• Safety observation – ED CNAs, psych techs
• Security and transport as needed – LEAs or designee
• Provide “just in time” services

TEAM TRAINING

Mental Health First Aid, Management of Aggressive Behavior, Crisis Assessment and Safety Planning

IDAHO

SUGGESTIONS FOR RURAL AREAS

Use of Sequential Intercept Mapping as a planning tool Use of telehealth for crisis response and psychiatry

24/7 BH support to LEA and hospitals – regular communication, meetings, joint protocols

Behavioral health training for law enforcement A basic place to keep a person overnight

• staffed with a paraprofessional or nurse, with a BH professional available for consult

MOUs among BH, LEAs, P&P, courts

• E. OREGON

FOCUS ON LAW ENFORCEMENT, COURTS AND HOSPITALS

BEHAVIORAL HEALTH PROFESSIONALS THAT ONLY TAKE LEA AND COURT REFERRALS

• mobile crisis services during business hours/next day service
• work with client for 30 days
• work in any setting necessary – homes, jails…
• assure people don’t fall through cracks

BEHAVIORAL HEALTH PROFESSIONALS ASSIGNED TO EDs LAW ENFORCEMENT TRAINING

• Including CIT adapted to rural areas

CLOSE COLLABORATION SKYPE IN SOME AREAS

MISSOURI

Training for law enforcement Intensive case management Data sharing to enable warm hand-offs Enrollment in Medicaid inside jails Respite services for consumers and family members Restoration/sobering place in lieu of jail - link to services Higher levels of care when needed

NACBHDD

KEY COMPONENTS OF HIGH-FUNCTIONING RESPONSE SYSTEM

WORKFORCE SUGGESTIONS

WICHE

Maximize use of mid-level providers supported by telehealth Use paraprofessionals and EMTs with support Train all responders in MHFA, some in CIT and assure training has a balance of info on MH, SUD and co-

• ccurring

Train and educate place committed people

INTERCEPT ZERO: COMMUNITY CRISIS SERVICES SAMSHA GAINS CENTER

• Maximize use of crisis lines and response teams (can be virtual) to

divert and avoid transports

• Clear, consistent communication between crisis line, 911, LEA
• ED well connected to BH, with BH embedded if possible
• Connect with community services within 24-48 hours when leaving ED
• EMS trained in BH, underutilized resource
• Peers involved in initial response and after

INTERCEPT ONE: LAW ENFORCEMENT SAMSHA GAINS CENTER

• LEAs trained in BH (MH and SUD) and well connected to BH providers
• BH and LEAs develop and refine response model, meet regularly
• Specialized Policing Teams
• Crisis Intervention Teams (CIT)
• Co-responder teams
• Follow-up teams
• Can involve peers

INTERCEPT TWO: INITIAL DETENTION & COURT HEARINGS SAMSHA GAINS CENTER

• Regular communication among LEA, BH, courts
• Pre-adjudication drug treatment courts
• Screen for MH and SUD and divert to treatment when possible,

divert Veterans to VA programs

• Courts more likely to divert if programs are in place

INTERCEPT THREE: JAILS AND COURTS SAMSHA GAINS CENTER

• Jails as HC settings need BH services and communication with BH provider
• National Commission on Correctional Healthcare resources
• Jails can use crisis line to connect prisoners to assessment and counseling
• Connect inmates with benefits and meds before release
• Drug Treatment Courts
• Community Courts
• Mental Health and Co-occurring Courts
• Deferred prosecution for low level, low risk offenders

INTERCEPT FOUR: RE-ENTRY SAMSHA GAINS CENTER

• Connection to:
• medications
• community-based treatment
• recovery support
• community-based services, including those that address SDOH (i.e.,

housing)

• Assertive Community Treatment Teams (PACT)
• Intensive Case Management Programs

INTERCEPT FIVE: COMMUNITY CORRECTIONS SAMSHA GAINS CENTER

• Specialty probation caseloads
• Forensic Assertive Community Treatment
• Housing and employment support

FOR CONSIDERATION…

• Statewide changes often were at play in the localities we

conducted interviews

• It is not possible to overlay a crisis system from one area to

another

• Think low tech and think high tech

Discussion

What 3 changes would you prioritize to begin developing a more effective system of prevention, treatment enforcement/diversion in Yellowstone County?

Create meaningful categories

Vote for top two

• verall priorities

(Green)

Vote for two areas where YOU are willing to work (Red)

Vote for two areas you would focus on with $500K budget (Blue)

September 4-5: Action Planning

QUESTIONS? POINTS FOR ACTION?

406-431-9260 | lovelandk@gmail.com

406-465-0331 smilieconsulting@gmail.com

Health and Human Service Consulting

Population Health Partners, LLC

Jane Smilie, MPH, Principal